II. Indications

  1. Alcohol Dependence with tolerance and withdrawal risk

III. Contraindications

  1. Long-term intake of large amounts of Alcohol
  2. Abnormal laboratory findings
  3. Urine Drug Screen positive for other substances
  4. Acute illness
  5. Comorbid illness necessitating inpatient management
    1. Serious cardiopulmonary conditions
    2. Uncontrolled Diabetes Mellitus
    3. Acute moderate to severe infectious illness
    4. Serious psychiatric illness (e.g. Suicidal Ideation, Psychosis)
  6. Severe Alcohol Withdrawal symptoms (e.g. Stage 3, Delirium Tremens)
  7. Alcohol Withdrawal Seizure history
  8. Unable to sustain daily reevaluation
  9. Unsafe environment
    1. Lack of reliable social support
    2. Follow-up and contact difficult
    3. No reliable contact person to monitor patient
  10. Comorbid Benzodiazepine Dependence
  11. Prior failed outpatient detoxification
  12. High risk for Delirium Tremens
    1. See Delirium Tremens for risk factors

IV. Labs

  1. Comprehensive metabolic panel
  2. Complete Blood Count
  3. Urine Drug Screen
  4. Blood Alcohol level

V. Management: Medications

  1. Benzodiazepines
    1. Administered based on either symptom-triggered protocol or fixed dose protocols (see below)
    2. First-line, long-acting Benzodiazepines
      1. Preferred for self-tapering and less addictive
      2. Diazepam (Valium) 10 mg every 6 hours prn
      3. Chlordiazepoxide (Librium) 25-50 mg prn
        1. Preferred agent overall (less stimulation of reward system, lower abuse potential)
        2. Maximum 300 mg/day
        3. Consider during ED evaluation in patients at risk and with early signs of withdrawal
          1. Consider single dose of Chlordiazepoxide (Librium) 50 mg orally
    3. Short-acting agents (higher abuse potential but preferred in elderly, liver dysfunction)
      1. Ativan (Lorazepam) 1-2 mg prn every 6 hours prn
      2. Oxazepam (Serax) 15 mg every 6 hours prn
  2. Benzodiazepine Alternatives (in patients in whom Benzodiazepines are considered too risky)
    1. These agents do NOT prevent withdrawal Seizures or Delirium Tremens
      1. Consider these agents primarily as adjuncts or for mild symptoms (CIWA-Ar <10, SAWS <12)
    2. Carbamazepine
      1. Effective in moderate withdrawal
      2. Dosing: 200 mg four times daily tapered over 5 days
        1. Start at Carbamazepine (Tegretol) 800 mg on day 1
        2. Finish at 200 mg once on day 5
      3. References
        1. Malcolm (2002) J Gen Intern Med 17:349-55 [PubMed]
    3. Gabapentin
      1. Potentiates CNS GABA activity and decreases glutamate activity
        1. Decreases Alcohol craving and depression
      2. Dosing (minimum effective daily dose 900 mg/day)
        1. Start 600 mg three times daily for 3 days
        2. Then 300 mg three times daily for 3 days
      3. References
        1. Stock (2013) Ann Pharmacother 47: 961-9 [PubMed]
        2. Myrick (2009) Alcohol Clin Exp Res 33(9): 1582-8 +PMID:19485969 [PubMed]
  3. Adjunctive medications in all patients
    1. See Alcohol Withdrawal
    2. Vitamin Deficiency is common (Vitamins A, C, B1, B3, B6, B9, B12)
      1. See Alcohol Dependence
    3. Thiamine 100 mg orally daily
    4. Folic Acid 1 mg daily
    5. Multivitamin Daily
  4. Adjunctive adrenergic symptom control to consider as needed
    1. Clonidine (Catapress) 0.2 mg twice daily prn
    2. Atenolol (Tenormin) 100 mg daily (50 mg daily for Heart Rate <80 bpm)
      1. Avoid in general, as these mask withdrawal signs

VI. Management: Symptom-Triggered Regimen

  1. Clinical Institute Withdrawal Assessment (CIWA-Ar)
    1. http://addiction-medicine.org/files/15doc.html
    2. Initially assess four times daily
    3. Assessment done by friend or family member
  2. Short Alcohol Withdrawal Scale (SAWS)
    1. Patient completes four times daily
  3. Benzodiazepine dose indication
    1. CIWA-Ar Score >9 points OR
    2. SAWS Score 12 or more
  4. Chlordiazepoxide (Librium) Protocol (with prn based on indications listed above)
    1. Prescribe Chlordiazepoxide 25 mg tabs (#11-22)
    2. Day 1: Librium 25-50 every 4 hours prn
    3. Day 2: Librium 25-50 every 6 hours prn
    4. Day 3: Librium 25-50 every 6 hours prn
    5. Day 4: Librium 25-50 every 12 hours prn
    6. Day 5: Librium 25-50 every 12 hours prn
  5. Diazepam (Valium) Protocol (with prn based on indications listed above)
    1. Prescribe Diazepam 10 mg tabs (#18)
    2. Day 1: Valium 10 mg every 4 hours prn
    3. Day 2: Valium 10 mg every 6 hours prn
    4. Day 3: Valium 10 mg every 6 hours prn
    5. Day 4: Valium 10 mg every 12 hours prn
    6. Day 5: Valium 10 mg every 12 hours prn
  6. Lorazepam (Ativan) Protocol (with prn based on indications listed above)
    1. Prescribe Lorazepam 1 mg tabs (#15)
    2. Day 1: Ativan 2 mg every 6 hours prn
    3. Day 2: Ativan 2 mg every 6 hours prn
    4. Day 3: Ativan 1 mg every 8 hours prn
    5. Day 4: Ativan 1 mg every 12 hours prn
    6. Day 5: Ativan 1 mg every 12 hours prn

VII. Management: Fixed Dose Protocol

  1. Reduce dosage if over-medication occurs
  2. Monitoring by reliable friend or family member
  3. Chlordiazepoxide (Librium) Protocol (preferred agent)
    1. Prescribe Chlordiazepoxide (Librium) 25 mg tabs (#11-22)
    2. Option 1
      1. Day 1: Librium 25-50 mg every 6 hours scheduled
      2. Day 2: Librium 25-50 mg every 8 hours scheduled
      3. Day 3: Librium 25-50 mg every 12 hours scheduled
      4. Day 4: Librium 25-50 mg at bedtime scheduled
      5. Day 5: Librium 25-50 mg at bedtime scheduled
    3. Option 2
      1. Day 1: Librium 50 mg every 6-12 hours
      2. Day 2: Librium 25 mg every 6 hours
      3. Day 3: Librium 25 mg every 12 hours
      4. Day 4: Librium 25 mg at night
    4. Option 3
      1. Librium 25-50 mg every 8 hours for 3 days
      2. Consider for emergency department discharge (lower risk)
      3. Patient follow-up with primary care or addiction medicine
  4. Diazepam (Valium) Protocol
    1. Prescribe Diazepam 10 mg tabs (#11)
    2. Day 1: Valium 10 mg every 6 hours scheduled
    3. Day 2: Valium 10 mg every 8 hours scheduled
    4. Day 3: Valium 10 mg every 12 hours scheduled
    5. Day 4: Valium 10 mg at bedtime scheduled
    6. Day 5: Valium 10 mg at bedtime scheduled
  5. Lorazepam (Ativan) Protocol
    1. Prescribe Lorazepam 1 mg tabs (#18)
    2. Day 1: Ativan 2 mg every 8 hours scheduled
    3. Day 2: Ativan 2 mg every 8 hours scheduled
    4. Day 3: Ativan 1 mg every 8 hours scheduled
    5. Day 4: Ativan 1 mg every 12 hours scheduled
    6. Day 5: Ativan 1 mg at bedtime scheduled

VIII. Precautions: Medical supervision

  1. Daily medical evaluation when CIWA-Ar >8, typically up to 5-7 days
    1. Review of Short Alcohol Withdrawal Scale (SAWS)
    2. Evaluations may be performed by any health care professional (e.g. RN, medical provider)
    3. Modify based on symptom severity (increased or decreased)
  2. Anticipate 5-7 days of withdrawal
    1. Highest risk of Delirium Tremens at 24-72 hours after stopping Alcohol
    2. Consider prn Benzodiazepine (e.g. Librium 25 mg) every 12 hours on days 6-7
  3. Face to face evaluations with Vital Signs are preferred
    1. Telemedicine may be used as needed
    2. Evaluate withdrawal severity
      1. Record Blood Pressure, Heart Rate
      2. Obtain Alcohol breath analysis
      3. Calculate CIWA-Ar or SAWS
  4. Symptom and sign review
    1. Hydration
    2. Sleep
    3. Mental status
    4. Mood
    5. Suicidality
    6. Substance use
  5. Education
    1. Review Alcohol Withdrawal expected course
    2. Review signs of severe Alcohol Withdrawal
    3. Maintain home low-stimulation environment
    4. Maintain hydration with non-caffeinated fluid
  6. Indications for Emergent referral to higher level of care (detox center, emergency department)
    1. Continued symptoms refractory to multiple doses of withdrawal medications
    2. Worsening or severe symptoms
    3. Persistent Vomiting
    4. Hallucinations
    5. Fever
    6. Delirium Tremens
    7. Confusion or Disorientation
    8. Seizures
  7. Following acute withdrawal protocol
    1. Refer to long term treatment
    2. Consider prescribing agents to maintain abstinence (e.g. Acomprosate, Naltrexone, Topiramate)
      1. See Alcohol Dependence Management for protocols

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